Integration Specialist/Registered Nurse
Program: Behavioral Health Home
Reports to: Clinical Supervisor
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This position is responsible for assessment and coordination of client health care needs in the Behavioral Health Home (BHH) program and providing expert consultation and guidance to staff regarding medication administration and health issues for clients.
Essential Job Functions
- Maintain the vision, mission and values of Touchstone Mental Health (TMH).
- Remain up-to-date regarding the various programs of TMH.
- Remain up-to-date regarding agency policies and procedures and perform all functions in accordance with TMH policies and procedures.
- Provide the highest quality of customer service consistent with TMH’s values and standards.
Supportive & Motivational Client Relations
- Establish supportive, motivational and therapeutic relationships with clients, ensuring an atmosphere of safety, security and responsible mental health care.
- Perform health screening and health assessment for all new admissions, and at critical junctures. Complete individual service plan with clients and work with the BHH team to participate in the development of recommendations for services or individual care plans.
- Meet with clients to discuss physical health concerns, wellness and treatment goals. Act as a wellness resource for clients and staff, providing training as needed.
- Serve as a role model and coach for clients regarding developing and using effective problem solving, decision-making, conflict resolutions, independent living skills and responsibilities.
- Advocate on behalf of clients in relation to the medical system. Encourage clients to use natural supports and mainstream community resources to support goals around living in the community. Provide clients with logistical and organizational support for planning and resolving potential barriers. Assist clients in scheduling health appointments and ensure transportation. Accompany clients to appointments, as needed.
- Coordinate delivery of services to effectively address client needs. Facilitate and coach clients in using natural supports and mainstream community resources to support goals around living in the community. Provide clients with logistical and organizational support for planning and resolving potential barriers. Refer clients in crisis to appropriate resources and provide follow up.
- Review clients’ knowledge of and compliance with medications and provide individual health education and medication monitoring/set up to assist in skill building for managing symptoms of their illness.
- As needed, assist clients and System Navigator in setting up and preparing for appointments, accompanying them to appointments as appropriate, and following up with the client.
Program Team Member
- Participate in team meetings and process to participate in communication concerning clients and facility.
- Consult with care coordinators and team members about identified health conditions of BHH clients and coordinate care with external providers as needed.
- Responsible for documenting information, within established timeframes (i.e. document within 3 business days of service), into the electronic health record and/or client registry, and updating the registry within established timeframes.
- Develop and nurture relationships with other community and social support providers to aid in effective referrals and timely access to services.
- Consult with care coordinators and team members about identified health conditions of BHH clients, including patient registry review and needed team actions in response to client status.
- Assist BHH team with prioritizing the team’s efforts in delivering services.
- Use the patient registry to conduct panel management, including:
- Design and implement new activities and workflows that increase client engagement, quality improvement and optimize clinical efficiency.
- Lead the BHH Team to select common clinical conditions and target cohorts on which to focus health interventions.
- Measure and monitor population data to identify outstanding health issues and gaps in care as well as to report on health status, quality metrics and outcomes for the target population.
- Obtain and implement technologies such as electronic health registry and reporting systems to facilitate data collection, client tracking and outcome reports.
- Deploy electronic and non-electronic tools to effectively make use of best practices and evidence to guide care efficiently and correctly.
- As assigned.
The work of this position entails the use of standard office equipment and medical equipment, including syringes. This position requires the ability to drive an automobile on a daily basis. This position is approved to use agency vehicles. The work of this position requires that the incumbent be able to see, hear, speak, read and write English clearly in order to ensure client welfare and development. The incumbent must be able to reach, use fingers and drive up to 2/3 of the hours worked; climb stairs, stoop, kneel, crouch, stand, walk, remain in a static position, push, pull, lift, use fingers, grasp, feel, perform repetitive motions, and carry up to 1/3 of the hours worked. The incumbent must also be able to lift up to 10 lbs from the waist, knee or floor and occasionally 25 lbs from the waist.
Education and Experience
- Licensed, registered nurse in the state of Minnesota.
- Experience working with adults with a serious mental illness preferred.
- Ability to maintain a clean driving record, a current driver’s license, and auto insurance coverage meeting Touchstone Mental Health policy limits.